26 june 2018 † nursing management ...€¦ · daily multidisciplinary rounding, which supports...

26 June 2018 • Nursing Management nursingmanagement.com26 June 2018 • Nursing Management www.nursingmanagement.com

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www.nursingmanagement.com Nursing Management • June 2018 27

1.5CONTACT HOURS

STAFFING SERIES PART 2

ast month, in the article “Developing a staffing plan

to meet inpatient unit needs,” we learned how to

determine the full-time equivalent (FTE) need for a

unit to ensure a quality and exceptional patient experi-

ence. Now that we know how many FTEs we need, the

next big question is: “How do you keep them in a pro-

ductive mode?” This article discusses not only how pro-

ductivity is calculated, but also gives you ideas on how to

keep your team in the green of productivity.

Measuring productivityBeing able to monitor the depart-

ment’s productivity is essential

but, unlike an industrial produc-

tion line, it isn’t easy for nursing

to quantify productivity. After

all, the work isn’t measured in

widgets made or wires soldered.

However, productivity can be

measured as a factor of volume

versus hours worked.

To evaluate the department’s

productivity, you must first

establish the target or goal for the

department if it were 100% pro-

ductive. The target is determined

Meeting the measurementsof inpatient staffing productivity

By Pamela S. Hunt, MSN, RN, NEA-BC, and Denise Hartman, MBA, BSN, RNC-NIC

Lwith the following formula: mea-

surement of work multiplied by

the budgeted hours per patient

day (HPPD) for a defined period

(usually the 14-day pay period).

Using the unit from the previ-

ous article, Med-Surg 2 South, as

our example, let’s say the mid-

night census for a 2-week pay

period adds up to a volume of

420. We already know that our

budgeted HPPD are 9.5. There-

fore, for this pay period, if the

unit were 100% productive, the

payroll report would show 3,990

productive hours worked (420

multiplied by 9.5 equals 3,990).

Now that we know what the

100% mark is, it’s necessary to

compare the goal or target hours

with the actual number of produc-

tive hours worked in the same

time period. The equation is:

target hours (census multiplied

by budgeted HPPD) divided by

actual productive hours worked.


Meeting the measurements of inpatient staffi ng productivity

28 June 2018 • Nursing Management www.nursingmanagement.com

Example: Med-Surg 2 SouthPercentage of productivity• Target hours: 3,990• Productive hours worked for the

same 14-day pay period: 4,370• 3,990 target hours/4,370 produc-

tive hours = 91.3% productivity for this pay period

Many hospitals are now track-

ing daily productivity. The same

equation is used for the daily

calculation, with 24 hours as the

time period instead of 14 days as

in the example.

Overtime percentageAnother useful measurement of

productivity is the calculation

of overtime (OT): actual number

of OT hours worked divided by

actual productive hours worked

equals OT percentage. This equa-

tion is used for the same time

period to determine what per-

centage of the total work hours

were worked using OT.

Example: Med-Surg 2 SouthPercentage of OT• OT hours: 125• Productive hours worked for the

same 14-day pay period: 4,370• 125 OT hours/4,370 productive

hours = 2.9% OT for this pay period

In healthcare, 2% OT is a rea-

sonable benchmark. The astute

nurse leader knows what’s caus-

ing the OT and works to reduce

these causes. Is the OT occurring

because of staffing vacancies that

haven’t been replaced? More

patient volume than was bud-

geted? Staff schedules not match-

ing the unit’s activity volume?

Staff not being held accountable

for finishing work on time and

completing efficient end-of-shift

reports? These are just a few

areas to investigate if OT is con-

sistently above your organiza-

tion’s target level.

Nonproductive hoursKnowing what percentage of the

department’s total paid hours is

nonproductive versus productive

is also a measurement of produc-

tivity. Let’s suppose that you’re

reviewing productivity reports.

You find that your productivity

in hours looks good, but your

salary dollars paid in the same

pay period are over budget.

What caused this variance? You

evaluate the number of nonpro-

ductive hours paid in the same

time period and find that many

employees were on paid time

off (PTO), getting paid but not

working at the bedside. This

caused the increase in salary dol-

lars while showing that the pro-

ductive hours worked are meet-

ing the department’s budgeted

target. Let’s examine the follow-

ing equation: actual productive

hours worked divided by total

paid hours equals percentage of

nonproductive paid hours.

Example: Med-Surg 2 SouthPercentage of nonproductive hours• Productive hours worked: 4,370• Total paid hours: 5,060• 4,370/5,060 = 86% productive

hours• 100% − 86% = 14% nonproduc-

tive time

Admissions, discharges, and transfersThe admissions, discharges, and

transfers (ADT) percentage for any

one unit is calculated by divid-

ing the number of ADT in a pay

period by the midnight census

for that same pay period. For

example, if in a 2-week pay period

the unit has 420 total patient

days (midnight census each night

added together) and the total ADT

for the same pay period is 273,

the ADT percentage is 65% (273

divided by 420 equals 65% ADT).

Based on benchmark data, a

typical med-surg unit may have

a 50% to 55% ADT. In the exam-

ple, 50% of the midnight census

would be 210 (420 multiplied by

50% equals 210). This unit had

273 ADT, so it had 63 ADT above

what was expected (273 minus

210 equals 63). Translating how

much nursing care is needed to

accommodate an additional 63

ADT is necessary.

In a very conservative estimate,

an ADT takes at least 1 hour of

nursing time. Therefore, you can

safely estimate that this unit has

earned 63 additional hours of

nursing care in the productivity

target, entitling it to 63 earned

hours for the 2-week pay period.

Example: Med-Surg 2 SouthPercentage of adjusted productivity• Productive hours required: 3,990

+ 63 ADT = 4,053 (new target for 100% productivity after ADT adjustment)

• Productive hours worked for the same 14-day pay period: 4,370 (the actual hours worked don’t change)

• 4,053/4,370 = 92.7% productivity (adjusted productivity percentage)

Remember that the produc-

tivity on this unit before the

ADT adjustment was 91%. This

may seem like a small amount

of improvement. Let’s put the

dollars to the improvement.

Consider the following equation:

hours variance multiplied by

actual hourly rate equals actual

variance.



Example: Med-Surg 2 SouthVariance justification• Before ADT adjustment: (3,990 − 4,370) × 28.00 = −$10,640

• After ADT adjustment: (4,053 − 4,370) × 28.00 = −$8,876

• Justification difference of $1,764• $1,764 × 26 pay periods per year

= $45,864 annualized

You should monitor your unit’s

ADT percentage periodically

to ensure that it’s close to the

benchmark. If there’s a consistent

variance, it can be used as justi-

fication to adjust the HPPD bud-

geted for the unit. A consistent

variance is no longer a variance;

rather, it’s expected activity.

Staffing efficientlyNow that you have a thorough

knowledge of FTE, productivity,

OT, and ADT, we’ll look at how

daily staffing decisions affect key

performance indicators and iden-

tify staffing efficiency strategies

that reduce costs while maintain-

ing quality care.

Balancing the need to provide

quality care, support nurse satis-

faction, and meet financial targets

becomes more challenging each

year. Labor costs make up most

hospital expenses, and nursing

is the largest group of hospital

employees. In addition, there are

many studies that link appropri-

ate levels of skilled nursing to

quality outcomes. The successful

nurse leader will develop staffing

strategies that support quality

care in an efficient manner.

To achieve this goal, the fol-

lowing assumptions are made:

quality care and efficient staffing

aren’t mutually exclusive, meet-

ing staffing targets is supported

by all levels of nursing leadership,

small inefficiencies will keep units

from meeting targets, decreasing

variation in staffing decisions will

improve productivity, and effi-

cient staffing supports quality care

by allowing for staffing up during

times of extreme acuity.

Key performance indicatorsThe departmental performance

or budget report compares the

actual versus budgeted amounts

of revenue, expense, and key

performance indicators, includ-

ing equivalent patient volume or

units of service, HPPD, salaries

per patient day (SPPD), supplies

per patient day, and FTEs used

to provide care. For most nursing

units, the measure of service is

patient days, which is determined

by combining inpatients, outpa-

tients, and outpatients in a bed.

HPPD can be divided into two

groups: productive and nonpro-

ductive hours. The type of hours

that go into each of these subac-

counts will vary, so it’s important

to know how your hospital man-

ages these hours.

An example of differences

between hospitals is that some

include orientation and educa-

tion in productive hours and

others may not. In general, pro-

ductive hours are those hours

staff members have worked in

direct patient care, as well as

some support hours such as

manager, meeting, and training

hours. Nonproductive hours are

those hours paid to staff mem-

bers when they haven’t worked,

including PTO; sick days;

holidays; and time for funerals,

jury duty, and so on. Likewise,

productive SPPD include the sal-

ary cost of all productive hours,

whereas total salary cost includes

the salary cost of both productive

and nonproductive hours.

Equivalent patient days are

made up of observation patients,

outpatients in a bed, and inpa-

tients. Payers reimburse observa-

tion patients and outpatients in a

bed by the number of minutes the

patient is in a bed. When the min-

utes accumulate to equal 24 hours,

the area is given credit for 1

patient day. For example, if a care

unit has three patients who each

stay 8 hours, this is equivalent to 1

patient day volume. Inpatients are

paid by a daily bed rate; the inpa-

tient day of discharge typically

isn’t reimbursed. It’s important to

be aware of this because there are

staffing strategies that can be used

to improve performance.

Arranging nursing assign-

ments in a way that allows two

nursing assignments to be com-

bined as one after discharges is

a way to match nursing hours

to the number of hours that

patients are in a bed. Many

institutions are implementing

daily multidisciplinary rounding,

which supports discharge edu-

cation and planning on admis-

sion, and facilitates the early

dismissal of patients on the day

of discharge. Multidisciplinary

rounding allows for improved

caregiver communication,

patient care, and discharge expe-

rience. Early discharge decreases

labor costs by flexing down staff

after dismissal. Another advan-

tage to early discharge is that it

opens up beds, allowing for the

smooth flow of patients through

the building. Managing patient

throughput is essential to ensur-

ing a constant readiness to serve.

Appropriate staffing numbersStaffing acuity systems and grids

are tools that can be used to

improve consistency in staffing




decisions; however, remember

that staffing tools shouldn’t super-

sede critical thinking. If quality

care can be delivered with fewer

resources than the grid shows,

then staffing down is appropri-

ate. If a unit is staffing to grid or

acuity and still not meeting its

productivity targets, the follow-

ing questions can be asked: Does

the grid reflect current staffing

plans/ratios? Does the acuity rat-

ing accurately reflect the time it

takes to care for a patient? Is there

an opportunity to change staffing

numbers/ratios at different daily

census points to improve effi-

ciency by matching resources with

unit activity and patient needs?

It’s important to realize that a

staffing grid calculator typically

looks at those hours in direct

patient care. Unless specifically

added into the calculations,

there are hidden hours that

won’t show up on this tool.

Depending on your institution’s

definition of productive versus

nonproductive hours, these hid-

den hours may include early

clock-ins; late clock-outs; and

manager, meeting, and training

hours. Using a typical nursing

unit as an example:

• shift staffing grid calculator

without hidden hours

—392 direct care hours in a 24-hour

period divided by 37.8 equivalent

patient days equals 10.37 HPPD

• shift staffing grid calculator

with added hidden hours

—2 hours: 4 staff members clock

out 30 minutes late

—10 hours: 5 staff members attend

CPR training for 2 hours each

—12 hours: 2 RNs are on orienta-

tion for 12 hours each

—2 plus 10 plus 12 equals 36

total hidden hours

—The new total productive

hours increases to 428 hours (392

direct care hours plus 36 hidden

hours)

—428 divided by 37.8 equivalent

patient days equals 11.32 HPPD.

The initial shift calculator

showed the HPPD at 10.37. After

adding in the hidden hours, the

true HPPD are 11.32—a difference

of 0.95 HPPD. Although many of

these hidden hours may be neces-

sary to support unit functions,

you need to be ever vigilant of the

number of these hours and look for

opportunities to minimize them.

Training and orientation of new

staff can be a huge drain on bud-

geted productive hours, making it

important to support staff engage-

ment and decrease staff turnover.

Drilling down to find the

number of early clock-ins and

late clock-outs allows you to

identify the reason for these

overages and initiate strategies

to decrease them. The previ-

ous example of end-of-shift

late clock-outs may seem like a

small number of hours related to

the total number of productive

hours used in a day, but early

and late clock-outs combined

with other overages quickly add

up and can be the difference

between meeting or not meeting

financial targets. In the example,

we showed 2 hours of late

clock-outs. Two hours of daily

late clock-outs over a month is

60 hours, or an additional five

12-hour staffing shifts.

Strategies to decrease late

clock-outs may include giving

staff members the same assign-

ment as the previous day, allow-

ing for faster report; looking for

opportunities to standardize shift

report, allowing for streamlining

of information; evaluating the

level of effective communication

between licensed and unlicensed

staff, ensuring a team plan with

the same priorities for the day;

having the charge nurse identify

RNs who’ve fallen behind on

documentation before the end

of the shift and take over patient

care, allowing the RNs to com-

If quality care can be delivered with fewer resources than the grid shows, then staffi ng down is appropriate.



plete their documentation and

leave on time; and mitigating

change-of-shift admissions and

transfers by streamlining the dis-

charge process.

Even the busiest units can

have an occasional low census

day; overstaffing just a few days

a month can have a negative

impact on overall productivity.

Low volume takes away econo-

mies of scale and can make staff-

ing assignments more difficult to

manage. A detailed, written, low

staffing plan is a key to ensuring

efficiency. Points to consider in a

low census plan include identify-

ing the census point at which the

charge nurse or manager is in

assignment, developing a plan to

consolidate patients to the same

geographic area to improve nurs-

ing workflow, creating guidelines

for voluntary and mandated can-

celing of extra staff, and promot-

ing the expectation that all staff

members are clocked out within

30 minutes of the given low cen-

sus time and they aren’t held over

to relieve for lunches or potential

patients that may never arrive.

Decreased variationThere are clear data showing that

process variation increases waste,

and the processes used to deter-

mine appropriate numbers of

staff are no exception. To ensure

quality care and efficiency, all

staff members who are responsi-

ble for making daily assignments

need to have a thorough orienta-

tion that includes patient safety

and regulatory concerns, how to

determine correct staffing num-

bers, licensed to unlicensed staff

ratios, when it’s appropriate to

staff down or up from the staff-

ing acuity or grid tool, and how

to access the chain of command.

You should oversee daily staffing

to identify coaching opportuni-

ties, including mentoring those

who are in charge on the night

and weekend shifts. On many

units, the census goes down on

the weekend and patient needs

may decrease on the night shift,

so it’s imperative to take advan-

tage of down staffing when the

opportunity presents.

Having a checks and balances

process ensures efficient and con-

sistent staffing between charge

nurses. Touch base with charge

nurses throughout the day and

evening to mentor, discuss staff-

ing plans for the following shifts,

and establish guidelines for the

charge nurse to contact you if

he or she believes that the plan

needs to change or if there’s a

need to staff above the acuity or

grid tool. Waiting until after the

shift to discuss the details of how

the staffing decisions should have

been implemented is too late.

Are you on the staffing bubble

or did you think you were getting

a new patient who never arrived?

Both situations have the potential

for overstaffing. Proactive discus-

sions with charge nurses regarding

these situations, along with well

thought-out staffing strategies, are

essential to avoiding staffing pit-

falls. When on the staffing bubble

and trying to determine to staff

up or down, it’s advisable to staff

down initially, with the option

of calling in additional help if

needed. It’s much easier to call in a

staff member than send one home

after he or she is in assignment.

To avoid the work of inappro-

priate transfers in and out of a

unit, develop written guidelines

that state the type of patients

appropriate for the area and

ensure that the charge nurse is

involved in the transfer deci-

sion. When able, avoid calling in

additional staff until the patient

arrives on the unit. It’s often pos-

sible to absorb a new patient with

current resources versus staffing

up. The charge nurse may take a

light assignment to get through

a busy time, take over another

RN’s assignment so that he or she

can take the admission, or give

a strong clinician an additional

patient with increased unlicensed

or charge nurse support. Many

hospitals have house supervisors

who may be able to assist with

care or they may know of another

area of the hospital that can send

a staff member for a few hours.

The consistent use of these lean

staffing strategies can lead to an

improvement in productivity.

Salaries per patient dayProductive SPPD are a result of

multiplying productive hours

worked by the average hourly

rate. There are many variables

that affect SPPD. It’s possible for

an area to meet its HPPD targets

but not the SPPD targets, and vice

versa. If an area is well staffed,

requiring very little premium pay,

and has low orientation expense,

the SPPD may be below target,

whereas the HPPD may be at or

above target related to low vol-

ume or high acuity. To keep SPPD

within target, staff to core so that

there are enough staff members

to meet the most frequently

occurring census, which leads to

decreased OT use, incentive pay,

and use of agency or resource

team nurses who receive a higher

hourly rate. There’s variation

between institutions, but, in

general, when value-added OT

expense exceeds 2% of the total

salary cost for an extended period,




it may be time to look at increas-

ing the core staffing. Adequate

core staffing is important to main-

tain quality and staff satisfaction,

and keep costs down by ensuring

staff members aren’t working

excessive hours above their FTE.

OT expense can be reduced

by creating a balanced schedule,

including weekends and holidays;

maintaining a 70-to-30 ratio of

full-time (0.9 FTE) to part-time

staff to ensure minimal use of

weekend-only staff and provide

adequate holiday coverage; ensur-

ing all regular and as-needed staff

members are working their full

FTE or contracted hours; develop-

ing clearly written PTO guidelines

to minimize staffing holes; cross-

training staff from like units to

allow floating between units in

place of OT staff; and coaching

staff members who have persis-

tent OT hours. Creating a bal-

anced schedule includes a proper

skill mix of licensed to unlicensed

staff. Nurses should be working

at the top of their license while

unlicensed staff members provide

care that doesn’t require a license

and can be done safely within

their scope of practice.

Hiring nursing students in

the nonlicensed role is a win-

win. This provides clinical and

critical-thinking experience for

the student while increasing the

number of nurse extenders. This

can be especially helpful in the

summer when many students are

looking for full-time hours and

many RNs are requesting PTO.

During times when premium pay

must be used, it’s important to

have clearly written guidelines

that state when this pay is used

and that staff members who

are receiving premium pay are

the last to be used and first to

be released when patient needs

decrease.

EngagementThe current nursing shortage is

projected to get worse, making

turnover costly and a potential

quality of care concern. Creat-

ing an environment of trust and

mutual respect between nurses,

physicians, and administration

leads to increased engagement.

Taking the time to listen and

respond to staff concerns regard-

ing the physical work environ-

ment and conducting time trials

and environmental assessments

demonstrate administrative sup-

port. For example, purchasing

BP cuffs and pulse oximeters for

each room, using bedside carts

that contain admission and daily

supplies, providing bedside

computers along with a shelf

to place items, and furnishing

hydration stations where family

members can obtain water for

themselves or the patient allows

staff more time at the bedside,

increases organization, and

improves efficiency.

Nursing or unlicensed staff

turnover can be costly in loss of

valued experience and dollars.

Selective hiring is crucial for staff

stability, and hiring the right fit

for an area is important to create

a positive work environment.

Encouraging high performers

to refer potential hires is a great

way to recruit other talented staff

members. The development of

a well-designed clinical orienta-

tion program, skilled preceptors,

support tools, and postorienta-

tion mentorships is essential to

new hire longevity. To help offset

orientation costs, it’s important

to identity areas of concern early

so that the new hire receives

timely support and can complete

his or her orientation on sched-

ule. Near the end of orientation,

when trainees are taking full

assignments, it may be possible

for one preceptor to work with

two new staff members versus

1:1 training. This helps decrease

Creating an environment of trust andmutual respect between nurses, physicians, and administration

leads to increased engagement.



preceptor costs and encourages

new hires to function in a more

independent manner before com-

ing off orientation. Lastly, all staff

members should be encouraged

to take personal accountability for

their professional development

and that of their peers. Creating

a high-functioning team requires

all staff members to mentor and

support new hires, as well as one

another. It takes a village!

Staying in the greenMeeting measurements of pro-

ductivity can be both difficult

to understand and frustrating.

However, it’s critically impor-

tant to the organization, the care

team, and the delivery of quality

patient care that you understand

and know how to respond to

fluctuations in productivity.

Close monitoring of staffing and

implementation of the sugges-

tions presented in this article

will equip you to provide quality

care in the most efficient manner.

Knowledge, attention, and action

are the keys to success. NM

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Syst Rev. 2011;(7):CD007019.Cho SH, Mark BA, Knafl G, Chang HE, Yoon HJ. Relationships between nurse staffing and patients’ experiences, and the mediat-ing effects of missed nursing care. J Nurs

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Management for Nurse Managers and

Executives. 4th ed. Philadelphia, PA: Saun-ders; 2012.Geiger-Brown J, Trinkoff AM. Is it time to pull the plug on 12-hour shifts?: Part 1. The evi-dence. J Nurs Adm. 2010;40(3):100-102.Hill K, Higdon K, Porter B, Rutland B, Vela D. Preserving staffing resources as a system: nurses leading operations and efficiency initiatives. Nurs Econ. 2015;33(1):26-35.Hunt P, Laughon D. The Nurse Leader’s

Guide to Business Skills. Danvers, MA: HCPro, Inc.; 2011.Malloch K. Measurement of nursing’s complex health care work: evolution of the science for determining the required staff-ing for safe and effective patient care. Nurs

Econ. 2015;33(1):20-25.Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and

the quality of care in hospitals. N Engl J

Med. 2002;346(22):1715-1722.Pruinelli L, Delaney CW, Garciannie A, Caspers B, Westra BL. Nursing management minimum data set: cost-effective tool to demonstrate the value of nurse staffing in the big data sci-ence era. Nurs Econ. 2016;34(2):66-71, 89.Robert Wood Johnson Foundation. Facts and controversies about nurse staff-ing policies. www.rwjf.org/en/library/research/2007/10/cnf-nursing-staffing-policies.html.Toussaint J. On the Mend: Revolutionizing

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Pamela S. Hunt is the vice president of patient services and chief nursing executive for the north region of Community Health Network in Indianapolis, Ind., chairperson of Nursing Management Congress2018, and a Nursing Management editorial board member. Denise Hartman is a performance excellence consultant for the patient care division of Community Hospital North in Indianapolis, Ind.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

DOI-10.1097/01.NUMA.0000533765.82263.65

INSTRUCTIONSMeeting the measurements of inpatient staffing productivity

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